UNICARE Life &
Health Insurance Company has created the Individual
Dental Fee for Service Plan to help keep your teeth
healthy and your smile bright. The UNICARE Individual
Dental Fee for Service Plan offers you the choice of
going to any dentist you choose. Hundreds of dedicated
professionals have contracted with UNICARE Life &
Health Insurance Company to provide a wide range of
dental services such as routine check-ups, cleanings,
fillings, crowns and dental surgery. When you
choose a contracting dentist, you will receive care
at negotiated, discounted rates.

The UNICARE Individual Dental
Fee for Service Plan carries a yearly $50 deductible
per person (maximum of three deductibles per family).
All dental benefits are limited to a maximum payment
of $1,000 for expenses incurred by each enrolled member
during a calendar year. Should you choose
a noncontracting dentist, the plan still provides benefits,
but your out-of-pocket expenses may be greater, as the
negotiated fees do not apply to noncontracting dentists.
You will be responsible for any charges in excess of
the stated benefit. Your current dentist already
may be a contracting dentist. Be sure to check
the UNICARE
dental directory before you choose a dentist.
It could save you money.

A fewer number of contracted
dentists are available in other areas. UNICARE
plan members are entitled to the benefits of the negotiated
amounts if they choose one of those contracted dentists.
Benefits are still available for noncontracting dentists,
as specified by the plan. If you would like your
dentist to become a contracted dentist, please have
him or her contact us.

Dental Benefit Schedules

Coverage is provided ONLY for
the services stated in the following schedules.
To use these schedules, determine your dentist's fee
then look up how much the plan pays. Then you
can easily calculate what you will pay for a specific
service after your deductible has been met. The
plan pays either the specified amount, or the actual
amount charged by your dentist, whichever is lower.
You are responsible for any charges in excess of the
stated benefit.

Contracting
Dentist

Noncontracting
Dentist

If
the billed charges are$705

If
the billed charges are$705

And
UNICARE's negotiated rate is$455

UNICARE
will pay the amount specified in the benefit schedule$170*

UNICARE
will pay the amount specified in the benefit schedule$170*

Therefore,
you pay the difference between the negotiated amount
and the scheduled benefit$285

Therefore,
you pay the difference between the billed amount
and the scheduled benefit$535

* This assumes any deductible
has been met and you have not reached your annual maximum.

Preventive & Diagnostic
Care

Begins upon
approval of your application

Two oral examinations
and two dental cleanings per member, per year

Procedure

The Plan
Pays

Initial
Oral Exam

$13

Periodic
Oral Exam, Limited to 2 per member, per year

$13

Emergency
oral exam

$13

Bitewing
X-rays - single film

$6

Bitewing
X-rays - two films

$11

Single
(periapical) X-rays - first film

$7

Single
X-rays - additional films

$7

Bitewing
X-rays - four films

$16

Full mouth
X-rays, limited to one set every 3 years

$31

Routine
cleaning, limited to 2 per adult per year

$28

Routine
cleaning, limited to 2 per child per year

$21

Cleaning
with fluoride, limited to 2 per child per year

$28

Topical
fluoride only, limited to 2 per child per year

$9

Notes:

Total benefit for single
and bitewing x-rays not to exceed cost of full mouth
- $31 at noncontracting dentists.

Adult - Any person
or dependent 19 years or older covered by this plan.

Child - Any person or dependent
18 years or younger covered by this plan.

Basic Dental Care

Coverage begins after the plan
has been in effect for six continuous months.

Procedure

The Plan
Pays

Filling
- one surface, primary

$24

Filling
- one surface, permanent

$28

Filling
- two surfaces, primary

$34

Filling
- two surfaces, permanent

$38

Filling
- three surfaces, primary

$42

Filling
- three surfaces, permanent

$45

Filling
- four or more surfaces, primary

$50

Filling
- four or more surfaces, permanent

$55

Extraction
- single tooth (simple)

$31

Extraction
- each additional tooth (simple)

$31

Surgical
extraction

$55

Removal
of impacted tooth - soft tissue

$75

Removal
of impacted tooth - partial bony

$95

Removal
of impacted tooth - complete bony

$115

Major Dental Care

Coverage begins after the plan
has been in effect for twelve continuous months.